IHD stones are a prevalent disease in Southeast Asia and the incidence in the Korean population has been reported to be 15% of all biliary tract stones, which is relatively higher than the data reported for Western populations [7
Hepatectomy was considered the most effective and safe procedure with a high stone clearance rate, low morbidity and a low long-term stone recurrent rate. For treatment of IHD stones, hepatectomy is a safe and useful treatment that can remove stones and associated pathologic changes, including ductal stricture, microabscess, and fibrosis by a single operation [4
Laparoscopic liver resection has developed more slowly than others because of the complex anatomy of liver, the technical difficulty, the risk of massive bleeding, air embolism and the relatively long learning curve [8
]. However, with the accumulated experience of surgeons and the improvement of laparoscopic instruments, an increasing number of reports on laparoscopic liver resection for various hepatic lesions have been reported. However, there have been only a few reports on laparoscopic liver resection for IHD stones [10
From 2008, laparoscopic procedures have been performed for IHD stones in Gyeongsang National University Hospital.
In the early period, 11 patients with IHD stones underwent laparoscopy-assisted hepatectomy. For mobilization of the left liver, the ligaments around the left liver were sharply dissected laparoscopically until the left hepatic vein was exposed. Then, an approximately 10 to 15 cm sized upper midline skin incision was created. Hepatic parenchymal transection was performed in the same manner as open technique. Based on these experiences, total laparoscopic liver resection was performed in the late period.
Most laparoscopic liver resection is performed using 4 to 7 trocars. Selecting the positions of the trocars is crucial for liver retraction to secure an accurate field of vision and for facilitating handling of laparoscopic instruments. We used 5 trocars (three 10-mm trocars and two 5-mm trocars) in all patients.
Laparoscopic liver resection for IHD stones is more technically demanding because of severe perihepatic adhesion and anatomic distortion resulting from the recurrent inflammation.
In addition, parenchymal transection is often difficult because of parenchymal fibrosis.
Difficulty of hemostasis is a major concern in laparoscopic liver resection and is a major cause of open conversion [6
]. To avoid massive bleeding during parenchymal transection, the Pringle's maneuver has been used in some laparoscopic liver resections [9
]. Pringle's maneuver was not used in our cases. Before parenchymal transection, the hepatic artery and left portal vein were isolated and ligated individually. Selective inflow occlusion is more technically demanding than total vascular occlusion in cases of IHD stones because of the peripheral adhesion or anatomic distortion resulting from recurrent inflammation. But it can prevent complications of ischemic reperfusion injury and gastrointestinal congestion [17
]. Furthermore, selective inflow occlusion allows surgeons to the take time needed for meticulous dissection because it does not require fast liver transaction [19
]. To prevent complications such as biliary fistula, parenchymal dissection should be more carefully performed because of parenchymal fibrosis and deformed intraheptaic biliary anatomy.
The stone clearance rate after open surgery has been reported to be 75 to 98% [4
]. Since, by comparison, the stone clearance rate after laparoscopic surgery has been reported to be higher than 80%, there is no significant difference between the two groups [10
]. In our study, the initial stone clearance rate was 92.3% and the final stone clearance rate was 100%. Our data showed a similar outcome for the stone clearance rate. The use of intraoperative choledochoscopy or intraoperative ultrasonography could further raise the stone clearance rate.
In conclusion, laparoscopic hepatectomy for IHD stones is compare to open hepatectomy in results of stone clearance rates. Therefore, laparoscopic surgery could be an effective treatment option for the management of IHD stones in selected patients.